NHS Never Events: The Most Common Medical Accidents April 2019 – February 2020

The term ‘Never Event’ was first introduced by Ken Kizer, former chief executive of the National Quality Forum in the United States and was in reference to particularly shocking medical errors which should never occur if the available preventable measures are implemented.

An NHS Never Event is an umbrella term for a series of avoidable mistakes and errors made by NHS employees which could lead to a NHS negligence claim.

Categories of ‘Never Events’ include:

• Retaining a foreign object after surgery eg. swab left behind after surgery
• Wrong site surgery or treatment
• Wrong implant or prosthesis fitted
• Medication errors where the wrong dose or the drug was administered or wrong method was used to administer the drug eg. Overdose of insulin due to abbreviations or the incorrect device or the overdose of methotrexate for non-cancer treatment
• Misplaced naso or gastric tube
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Wrong blood transfused
• Patient being scalded or falling from a bed, or due to faulty windows or show rails

In order to be classified as a ‘Never Event’ the incident must satisfy the criteria given in 4.3 to 4.6 of the “Never Events Policy and Framework (Revised January 2018)”, and require full investigation under the Serious Incident framework.

These criteria are:

4.3. Never Events are patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.

4.4. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.

4.5. For each Never Event type, there is evidence that the Never Event has occurred in the past – for example, through reports to the National Reporting and Learning System (NRLS) – and that the risk of recurrence remains.

4.6. Each Never Event type must be able to be clearly defined and its occurrence easily recognised – this requirement helps minimise disputes around classification, and ensures focus on learning and improving patient safety.

For more details on the definition please visit: https://improvement.nhs.uk/documents/2265/Revised_Never_Events_policy_and_framework_FINAL.pdf

The Consequences of Never Events

A patient will often require further treatment after a Never Event. The financial and operational costs of this corrective treatment place a further burden on the NHS. Never Events will often have devastating effects on patients and their families – resulting in psychological and physical trauma.

According to research published in the British Medical Journal, 11,000 lives may be lost due to safety concerns, with older patients being most affected. The extra treatment needed following incidents may cost at least £1 billion.

Occurrences of Never Events Between April 2019 – February 2020

A report of the Never Events which occurred between 1 April 2019 and 29 February 2020 revealed that 435 serious incidents occurred. These incidents met the previously published definition of a Never Event.

An analysis of Never Events between April 2019 – February 2020

Table 1: Never Events 1 April 2019 and 29 February 2020 by month of incident*

Table 2: Never Events 1 April 2019 and 29 February 2020 by type of incident with additional detail*

Type and brief description of Never Event                                                         Number
Wrong site surgery	218
Biopsy taken from gastrointestinal tumour rather than kidney	1
Central line intended for another patient	1
Cervical biopsy instead of colon/rectal biopsy	1
Circumcision instead of planned frenuloplasty	1
Colonoscopy intended for another patient	1
Colposcopy intended for another patient	1
Contrast injection to wrong breast	1
Cystoscopy instead of sigmoidoscopy	1
Cystoscopy intended for another patient	1
Fallopian tube removed in error when plan was to remove the appendix	1
Flexible cystoscopy intended for another patient	1
Gastroscopy instead of colonoscopy	1
Gastroscopy intended for another patient	1
Gastrostomy instead of colostomy	1
Guide wire positioned into wrong lesion	1
Hip injection intended for another patient	1
Incision to wrong eye lid	1
Incision to wrong finger	2
Incision to wrong side of gum	1
Incision to wrong side of knee	1
Incision to wrong testicle	1
Injection to carpal tunnel intended for another patient	1
Injection to face rather than neck	1
Injection to wrong breast	1
Injection to wrong eye	7
Injection to wrong eye muscle	1
Injection to wrong finger joint	1
Injection to wrong foot	1
Injection to wrong hip	1
Injection to wrong joint	1
Injection to wrong leg	2
Injection to wrong leg muscle	1
Injections to both eyelids instead of one	1
Injections to both eyes rather than one	1
K wires to wrong part of thumb	1
Knee injection instead of elbow aspiration	1
Laser eye treatment intended for another patient	1
Laser therapy to wrong eye	1
Lesion removed from neck instead of gum	1
Lumbar puncture intended for another patient	2
Needle aspiration of wrong lung	1
Needle aspiration to wrong lung	1
Ovaries removed when plan was to conserve them	1
Part of pancreas removed instead of adrenal gland	1
Perineal fistulotomy instead of incision and drainage of pilonidal abscess	1
Pilonidal sinus excised instead of groin abscess	1
Removal of wrong breast lesion	1
Screws removed from wrong toe joint	1
Shoulder injection intended for another patient	1
Ureteroscopy intended for another patient	1
Varicose vein removal from the wrong leg	1
Wrong area of breast tissue removed	2
Wrong breast lesion removed	1
Wrong eye procedure	1
Wrong finger	2
Wrong finger incision	2
Wrong finger injection	1
Wrong hernia incision	1
Wrong hernia repair	1
Wrong lung biopsy	1
Wrong rectus muscle in squint surgery	2
Wrong side angiogram	2
Wrong side angioplasty	1
Wrong side ankle arthroscopy	1
Wrong side chest drain	3
Wrong side hernia repair	1
Wrong side labial lesion removed	1
Wrong side of leg	1
Wrong side of nose	1
Wrong side of toe	1
Wrong side of toenail removed	1
Wrong side parietal catheter	1
Wrong side spinal injection	11
Wrong side spinal surgery	2
Wrong side ureteric stent	2
Wrong side ureterorenoscopy	1
Wrong site block	53
Wrong site pleural aspiration	1
Wrong skin lesion biopsy	3
wrong skin lesion removed	14
Wrong testicle	1
Wrong toe	1
Wrong toe removed	1
Wrong tooth/teeth removed	38
Wrong vulval lesion removed	2
Retained foreign object post procedure	90
Angioplasty cover	2
Bladder loop	1
Bladder resectoscope tip	1
Corneal guard	1
Coronary wire	1
Guide wire – anterior cruciate ligament reconstruction	1
Guide wire – central line	14
Guide wire – chest drain	5
Guide wire – gastrostomy stent	1
Guide wire – long line	1
Guide wire – percutaneous coronary intervention (PCI)	1
Guide wire – PICC line	2
Guide wire – renal dialysis line	1
Guide wire – renal vascath	1
Guide wire – superior vena cava (SVC) cannula	1
Guide wire – ureteric stent	1
Intracranial pressure bolt washer	1
Intraoperative retractor sponge	1
Laser eye shield	1
Ophthalmic pars plana vitrectomy (PPV) port	1
Ophthalmic trocar	1
Part of a dental instrument	1
Part of a Jacques catheter	1
Part of a periosteal elevator	1
Part of a surgical needle	1
Part of a uterine manipulator	1
Part of a vascular ablation sheath	1
PEG insertion device	1
Renal catheter inserter	1
Rubber collar from uterine manipulator	1
Surgical forcep	2
Surgical needle	3
Surgical swab	18
Throat pack	1
Tip of resectoscope	2
Vaginal swab	15
Wrong implant/prosthesis	43
Femoral nail	1
Fracture fixation plate – right instead of left	1
Hip	9
Intramedullary nail	1
Intra uterine device	1
IUCD implanted that was not consented for	1
Knee	13
Lens	9
Shoulder	1
Shoulder plate	1
VP shunt valve	1
Wrong breast implant	1
Wrong compression screws for femoral nail	1
Wrong intrauterine device	2
Unintentional connection of a patient requiring oxygen to an air flowmeter	27
Patient connected to air flowmeter rather than oxygen	27
Misplaced naso or  gastric tube	21
Naso gastric tube in the respiratory tract and feed administered	21
Administration of medication by the wrong route	10
Enteral medication given intravenously	1
Oral medication given intravenously	7
Oral medication given subcutaneously	2
Mis selection of high strength midazolam during conscious sedation	6
Wrong strength midazolam administered	6
Overdose of methotrexate for non-cancer treatment	6
Methotrexate overdose prescribed and administered	6
Overdose of insulin due to abbreviations or incorrect device	6
Insulin withdrawn from an insulin pen	1
Wrong syringe	5
Transfusion or transplantation of ABO incompatible blood components or organs	5
Wrong blood transfused	5
Failure to install functional collapsible shower or curtain rails	1
Curtain rail failed to collapse	1
Mis selection of a strong potassium solution	1
Potassium administered instead of paracetamol	1
Mis selection of a strong potassium solution	1
Wrong strength potassium given	1
Total                                                                                                                                        435

 

The NHS publishes provisional Never Events data every month.

The NHS Patient Safety Strategy

Among the Initiatives introduced to reduce the occurrence of Never Events is the Patient Safety Strategy, published in July 2019. In the Strategy it was noted:

 

This strategy has two core issues: patient safety culture and patient safety systems.

The objectives of the strategy are:

• To improve the understanding of safety by drawing intelligence from multiple sources of patient safety information and the production of regular Patient Safety Alerts. These alerts require action to be taken by healthcare providers to reduce the risk of death or disability.
• Equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system.
• To introduce an adequate reporting system to record adverse events.
• The sharing of local information relating to risks and best practices among organisations. This is done at the sub-regional, regional and national levels
• The development of the The National Patient Safety Improvement Programme which looks into processes to:
  • Improve recovery and prevent deaths from Sepsis
  • Improving outcomes for mother and babies during pregnancy and childbirth
  • Improving the administration of medication
  • Improving care of elderly patients and reducing risk of harm
  • Improving the care for patients with mental health issues or disabled patients
  • Improving management of infections
• Publication of regular Patient Safety Guides

The scope of the NHS Patient Safety Strategy is not to punish mistakes made by NHS workers, but to learn from mistakes, ensure that they are not repeated in the future and improve patient outcomes.

Claiming Compensation for a Never Event

Devonshires Claims’ medical negligence solicitors are members of the Action Against Medical Accidents (AvMA) and the Association of Personal Injury Lawyers (APIL).

Our medical negligence compensation service provides:

• A free no-obligation case evaluation
• Advice on the probability of success for an NHS negligence claim and the amount of compensation you could potentially obtain
• Friendly, compassionate and experienced claims experts
• A No Win No Fee agreement i.e. you will not incur any costs if your claim is not successful*.
• Access to a network of medical experts and specialist barristers

If you or a family member has been affected by a ‘Never Event’, you may be able to claim compensation for medical negligence. For a free no-obligation case evaluation contact our experienced ‘No Win No Fee’ medical negligence solicitors. Our experts work hard to secure victims of medical negligence the justice and compensation they deserve.

Contact our claims experts today on 0333 900 8787, email [email protected] or complete our online form.